by Paul Bogard
Age has a lot to do with this, too. One classic example: the difference between a nineteen-year-old college student’s epic struggle to get to a 9:00 a.m. class, and the relative ease with which his fifty-year-old professor who’s been up since 5:00 a.m. gets there. It turns out that it’s actually natural for teenagers to want to go to sleep at two, three, four in the morning, which means that making them get up for school at seven in the morning is the equivalent of making a forty-year-old get up at three o’clock every day—in other words, cruel. That said, the fact someone might be a night owl doesn’t make her immune from the effects of staying awake all night. “There are individual differences,” says Steven Lockley, “and some adapt better than others. But virtually no shift worker is properly adapted. They might be slightly further down the continuum (of circadian disruption) than the people who are not as able to adapt to shift work, but they’re still being affected.”
“Tell him what you honestly think,” Michelle says as she introduces me to Chris and leaves to check on patients. “I paint a pretty glorious picture of the night shift.” Chris, a forty-year-old nurse in pale blue scrubs, tells me she likes working nights, too. At least, she did until her hours were changed two weeks ago, from 7:00 p.m.–3:30 a.m. to 9:00 p.m.–7:30 a.m. She’s been miserable since. “The other night I thought I was going to die,” she says. I tell her that’s certainly how I would feel with her schedule. But isn’t she used to it? “I’ve worked nights for twenty-one years,” she says. “And I think it’s just a neurotic way to live. I don’t think it’s normal. For instance, I have diabetes, so I probably would be in better health if I didn’t work nights. My physician has certainly told me that. It’s really not normal. I don’t think it’s very good for you. If I’m up all night, I notice my blood sugar is different. And when do you take your meds—do you take them like you’re a day person or a night person? So that’s been a big issue. Another thing, your motivation really goes down. I’ve been saying I want to go back to grad school for about ten years. I’m able to function in normal daily living—wash the dishes, clothes, drive my kids around—and I don’t feel like I’m forgetful necessarily, I just don’t feel like doing a lot.”
“See, I don’t know any different,” says another nurse, Marilyn, who’s come over to join us. “I started for convenience reasons, for daycare, when my kids were little. Now I just like the hours better. I have no trouble sleeping during the day. As a matter of fact at this point I sleep better during the day than I do at night. But I don’t have little kids at home anymore.”
“You’re not worried that a four-year-old is going to burn the house down?” Chris laughs.
“No, I am not worried.” Marilyn smiles. “Me and the dogs sleep all day together. I could care less. I’ve adjusted to it, I think. It is a very different lifestyle. People who have not done it don’t understand. My kids, it’s all they’ve ever known. To have a mom home every night and weekend would be weird to them. It’s how we’ve always done it.”
“I do it for convenience reasons,” Chris says. “I’d say money is not a good motivator for night-shift people.”
“Oh, no, no, no. Money has nothing to do with it,” Marilyn says.
“Some people say, ‘Oh well, you night people, you make a better wage than we do.’ ”
“That’s not why we do it.”
“It’s not worth it,” says Chris.
“It’s not worth it,” Marilyn echoes. “The people who do it want to work those hours. Nobody does it for the difference in pay, that’s for sure. That does not make it worth it, trust me.”
Chris leaves us (she’s the triage nurse tonight, and it’s time to update the digital bulletin board), and I ask Marilyn what does make working nights worth it.
“I love the atmosphere, the different personality of the people who work at night. The teamwork is better because there’s fewer people here. It’s more laid-back. We don’t have administrators running all over. Plus,” she says, “I’m in awe of people who can get up at five a.m. and go to work. I would rather stay up all night than get up at five a.m. And I also love to be home during the day and do my shopping when everybody else is at work.”
Amid the various flashing lights and beeps, intercom requests, and swirl of voiced questions and requests making the ER night’s soundscape (though, I notice, there is no background music—and not that I necessarily expected it, and what, after all, would it be?), an unseen woman’s pathetic wail rises again and again. None of the ER nurses or doctors seems to notice. When a man shouts, “Shut the fuck up!” Marilyn pauses. “That’s her husband talking to her, I believe,” she says quietly.
“I mean, you do feel tired,” she continues. “And a lot of people say they didn’t realize how bad they felt until they got off nights. I’ve had people who have worked nights for a long time tell me that. You have to make yourself get up and get going. You could lie around and be tired all the time. You just make yourself plug on. I mean, I’ve worked only nights for twenty years, and I know I’m going to be tired because I work nights. You just get used to being tired.”
I hear this often from those who profess to prefer nights, or to at least be “used to” them, But however true the night owl idea, the biological truth is that owls are owls, and humans are humans—and unlike the nocturnal bird, we have not evolved to be up all night. As Jeanne Duffy at Harvard’s Division of Sleep Medicine has said, “You can’t override your biology.”
That does not keep us from trying, of course.
“Well, we eat terrible,” says Marilyn, referring to what is one of the toughest biological challenges to working all night. “I went to the doctor the other day and they asked when did you last have a meal, and I said, ‘Three a.m., I ate dinner.’ ”
When Marilyn goes back to work I make my way over to talk with Steve, the charge nurse, who has worked the night shift for more than thirty years and, one of the other nurses will tell me, sometimes jokes, “I’d be a hundred pounds lighter if I didn’t work nights.” Steve will turn sixty this summer, and, yes, Steve is a big guy.
“I do think there’s an issue with weight,” he says. “When I entered the field almost forty years ago I was a skinny kid. And trying to keep the weight off is pretty tough. I don’t know if it’s cortisol or what. I find when I work more nights I’m hungry all the time. And that’s not as true when I’m working days.”
Nearly every night-shift worker I talked with admitted this challenge. When it’s slow you eat to stay awake, and when it’s busy you don’t have time to eat well, so you just grab “a bag of chips or whatever.” As though orchestrated for my visit, in the break room while I talk to Steve one of the security guards is raiding the cookie tray.
Harvard’s Lockley cites eating in the middle of the night as a good example of “messing with our internal clock,” in this case our metabolic rhythms. “If you eat pizza at two o’clock in the morning,” he says, “you’re more likely to get more indigestion than if you eat the same pizza at two o’clock in the afternoon. And that’s because our body clocks have not timed our digestive responses to be maximal at night; they’re maximal in the daytime.” So, if a person eats a meal at night, “you’re eating at a time when your biology is not able to metabolize the food properly, and so you end up with chronic elevation of insulin, glucose, and fats—which are risk factors for diabetes and cardiovascular disease. And shift workers have those increased risks.”
In my visits with those working the night shift nearly everyone admitted to the difficulty of fatigue, but few—even those in health care—were aware of the research indicating that fatigue was only part of the story. As the clock crept past 1:00 a.m. and I waited for Michelle to return to her desk, I thought about a discussion I’d had with a nurse from Albuquerque named Catherine. I’d asked her if she ever talked about the risks with her co-workers.
“No,” she said. “Nobody talks about anything like that. In fact, I don’t have a problem telling my boss that I want a day shift whene
ver one comes available, but telling her that it’s because I feel like I’m more at risk for breast cancer or whatever—she would look at me like, ‘Huh?’
“In my profession it’s an expectation that you will work nights,” she continued. “Not forever, but in nursing it’s just part of the culture that you work nights first. And then once you build seniority, you can apply for day positions as they come open. I never questioned the repercussions of it, because wanting to do hospital nursing, it’s just something that goes along with that career choice. That’s not really a justification for not being aware. But it’s just part of the job.”
The difference between Catherine and others I talked with is that she had made herself aware of the risks by reading some articles another nurse had sent her. A single parent in her early forties, Catherine has been struggling working at night. “For the last several months I’ve been having more and more difficulty, feeling more out of balance. I don’t know if you’ve ever had the experience of having a washer go out of balance. And it goes round and round, it’s just flinging around out of balance. That’s how I feel a lot of time, like I’m getting swung around and never can get back into a balanced cycle. And at the same time I’m feeling really like I want a change, but I’m not able to justify the money, because it is quite a bit more money—and so feeling that I just need to suck it up. But reading the articles really gave me that extra little bit of information that helped me reach my tipping point and say, There is a reason why I’m feeling this way. There’s a reason why I’m feeling depressed. There’s a reason why I’m so exhausted and not feeling well many times and many days. And it’s not worth the money anymore.”
It’s the stories of exhaustion that stay with me. Part of that is because in my visits with night-shift workers I have dipped my toe into how they must feel—my jaw-stretching yawns at the end of my custodial visit come to mind—but most of it is just hearing what these folks endure.
“What would be the best way to describe it?” says another nurse, Heather, when I ask what she means by feeling “all messed up.” “It’s like I’m there and I know what I’m doing, but two hours from now if I look back, I’ll be like, Gosh, did I do that? It’s like I can’t remember. I feel like I’m there but I’m not completely there. Like, it’s scary as hell to be driving home in the morning. You get home and you don’t even remember driving home. It’s like, Yeah, that’s probably not a good thing.”
Catherine admitted to me that she carries a prescription drug to keep her awake. “That’s another reason I don’t like this schedule. Because I feel like I have to take things to stay awake, and then I also have to take things to stay asleep, even times when I am just completely exhausted. I think the worst time in general that’s consistent for me is when I’m driving home. My drive home is about a half hour, and I feel like it’s really dangerous. There are days on a regular basis where I almost fall asleep at the wheel.”
Spending time in the ER makes me wonder how the night shift will change—if it will change—if more and more evidence pointing to serious health issues begins to accrue. Certainly we have a need for night-shift workers, in fact we as a society demand it. (As Michelle tells me, “You can’t just say, ‘Oh, you’re dying of a heart attack? Sorry, the hospital closed at 10:00 p.m.’ ”) But how much of the risk endured by those on the night shift is simply the result of convenience or profit? How much is a result of it being the easiest way for administrators to get things done, or of outdated traditions, such as scheduling resident physicians to work thirty-hour shifts twice a week?
“We may be at the same stage now as we were in the 1950s with smoking,” says Steven Lockley. “In the fifties, a few people thought smoking was bad, but there wasn’t publicly available evidence at that point. It’s only over the next thirty or forty years that evidence accrued to show, without doubt, that smoking causes lung cancer. Thirty years ago it would have been impossible to think of smoking being banned in public places, would have been laughed at. But that has happened. And it’s happened because of the secondary effects of smoking on other people. You have the right to smoke yourself to death if you like, but you don’t have the right to kill somebody else with your smoking. And so society has decided that those risks, those secondhand risks, are worth legislation and that we’ll all now have to abide by them.
“The same could be true of lighting or sleep loss,” he says. “The light from my neighbor’s yard may cause me problems, just like one person’s smoking was giving someone else lung cancer. Similarly, shift workers driving home drowsy after a night shift may fall asleep at the wheel and kill themselves—which is itself bad enough—but is completely unacceptable if they fall asleep and kill someone else also driving on the road. The effects of secondhand light or secondhand sleepiness should be considered in the same way as secondhand smoke. It’s only this type of thinking that will prompt real change.”
“This is what it looks like during the day in here,” Michelle tells me, returning to her desk. “The light levels are the same.” On cue, a nurse nearby offers a big yawn, then a quiet “uff da” like a good Minnesotan. (Wiki says, and I confirm, “Uff da is often used in the Upper Midwest as a term for sensory overload. It can be used as an expression of surprise, astonishment, exhaustion, relief and sometimes dismay.”) Because I know it is, in fact, no longer day in here, I almost expect everyone to be yawning to tears. Then again, it’s only 1:45, not yet between 2:00 and 4:00 a.m.—those toughest hours for staying awake—and I don’t see it.
The main thing I don’t see, though, is darkness, the natural darkness of the natural night. This emergency room has no windows, and there’s no way to know what’s happening in the night outside. It feels like a bunker, deep below the real world. And it’s this artificial separation from the natural night that I’m thinking of as I leave the emergency room and drive back across the city, seeing the world differently, terribly aware of the bright interiors I’m passing and of all the many people at work inside.
Sleep. We need it like we need food and water. It’s a biological need that we cannot overcome—not for long, at least. And yet many, many, many of us are not getting it: seventy million Americans suffer from disorders of sleep and wakefulness, and of these, 60 percent have a chronic disorder. When it comes to insomnia—the inability to sleep—some 20–40 percent of Americans experience it during the course of a year, one in three in a lifetime. In 2005, the National Sleep Foundation found that 75 percent of American adults experienced symptoms of sleep problems at least a few nights per week.
There is no shortage of books on sleep and sleep disorders, but few focus on the importance of darkness for good sleep, and the possible connections between short sleep and long light. Could our dozens of sleep disorders be directly related to our lack of darkness? At times it seems an obvious connection—we have all these sleep disorders and all this light—but a connection the medical sleep profession has been slow to pursue, let alone accept. Though hospitals all over the country have a “sleep center” to assist patients in solving their sleep disorders, few of these centers have been concerned with light at night.
But that may be changing. I spoke with two sleep professionals who argue that our struggle with sleep has much to do with our disregard for the dark.
“The challenge, at least for Americans, is becoming comfortable again with darkness,” says Dr. Vaughn McCall, head of the Sleep Center at Wake Forest Baptist Medical Center. “We don’t know what to do with ourselves when it’s dark and we’re awake.” In a thick Carolina accent, McCall tells me he sees “lots and lots” of insomniacs, most of whom stress over the question, “Why am I awake in the middle of the night?” The understanding that this waking was probably a normal part of the human experience, McCall argues, is one we have lost with the advent of electric lighting. “When you look at diaries from the nineteenth century, you get the sense that a hundred fifty years ago, when it was dark people got in bed, and when there was light they got up. They were entrained
more or less to the natural photoperiod. People might be in bed for nine or ten hours at a stretch, though not necessarily with the expectation of sleeping all that time.”
In fact, that’s exactly what historian Roger Ekirch found while researching At Day’s Close—in western Europe and colonial North America before electric lighting, people went to bed when the day’s light ended and got up when it returned, but without expecting to sleep throughout the night. Instead, on most nights they experienced two major intervals of sleep, called “first sleep” and “second sleep,” with an hour or more of “quiet wakefulness” between. Ekirch found that “men and women referred to both intervals as if the prospect of awakening in the middle of the night was common knowledge that required no elaboration.” In other words, this pattern did not create panic. Instead, people took advantage of these periods of “quiet wakefulness” to converse with their partner, make love, pursue hobbies, or even visit friends. For many, this time of waking offered freedom and opportunity the day did not allow, true especially for women who finally had time to themselves, free from the day’s toils and troubles, patriarchal hierarchies, and burdens. Ekirch discovered a second major difference between modern sleepers and our ancestors: “most members of preindustrial households probably did not drift quickly to sleep. Whereas the current time for lapsing to sleep averages from ten to fifteen minutes, the normal period three hundred years ago may have been notably longer.”
To my modern ears, having the time and mind-set to hang out in bed for two hours before sleeping sounds pretty great, maybe even a little decadent. A good book—even if by candlelight? A partner you love, and want to love—especially by candlelight, or maybe with a fire in the fireplace? Maybe you’re sleeping outside and the night sky has your attention. But in the twenty-first century, it wouldn’t be surprising if there were a medical term for this “condition,” or if it were perceived as nearly un-American in its lack of productivity. Indeed, for many, being in bed but not being able to get to sleep can cause pressure to build. It doesn’t help, McCall says, that sleep has become idealized, like many aspects of human behavior.